Outpatient Rehabilitative Services

Harford Memorial Hospital
501 South Union Avenue
Havre de Grace, MD 21078
443-843-5331		 Physicians Pavilion II
Suite 514
510 Upper Chesapeake Drive
Bel Air, MD 21014
443-643-3257		 Sports Medicine & Rehabilitation Center
Y at Abingdon
101 Walter Ward Blvd.
Abingdon, MD 21009
443-409-0051
 
History Survey

Name:
Date of Birth: (Month/Day/Year) - -

Please take a few minutes to complete this Health Status Survey. Your responses will give us very valuable
information regarding your overall health, and will help us take better care of you.  Thank You.

1. Current Condition(s)/Chief Complaint(s)
 
a.
 Describe the symptom(s) for which you seek therapy:
   
 
b.
 When did the symptom(s) start (date)? - -
 
c.
 Have you ever had the symptom(s) before? NO YES
    What did you do for the symptom(s)?
   
    Did the symptoms get better? NO YES
 
d.
 What makes the symptom(s) better?
   
 
e.
 What makes the symptom(s) worse?
   
 
f.
What are your goals for therapy?
   
 
g.

Are you seeing anyone else for the symptom(s)?  Check all that apply:
   
Acupuncturist Massage Therapist Osteopathic physician
Cardiologist Neurologist Pediatrician
Chiropractor Obstetrician/Gynecologist            Podiatrist
Dentist Orthopedist Primary Care Physician
Family Practitioner Nurse Practitioner Rheumatologist
Internist Surgeon Other:
2.

Medications
 
a.

Do you take any prescription medications:
    NO YES  
    Please list them:  
   
 
b.

Do you take any over the counter (non-prescription) medications? Check all that apply:
   
Advil / Ibuprofen Aleve / Naproxen Other:
Antacids Decongestants Other:
Aspirin Herbal Supplements Other:
3.

Allergies
 
a.

Do you have any known allergies or adverse reactions to any prescription(s) or over the counter medications?

    NO YES  
    Please list them:  
   
4.

Clinical Tests:  Within the past year, have you had any of the following tests? Check all that apply:
   
Angiogram Doppler Ultrasound Myelogram
Arthroscopy Echocardiogram Nerve Conduction Velocity
Biopsy  EEG Pulmonary Function Test
Blood Tests EKG (Electrocardiogram) Spinal Tap
Bone Scan EMG (Electromyogram) Stress Test (e.g., treadmill)
CT Scan MRI X-rays
Other:        
5.

Medical History
 
a.

Have you ever had? Check all that apply:
   
Arthritis Broken Bones / Fractures Thyroid Problems
Cancer Osteoporosis Head Injury
Muscular Dys. Kidney Problems Heart Problems
Parkinson’s Repeated Infections High Blood Pressure
Seizures/Epilepsy Ulcers / Stomach Problems Lung Problems
Allergies Skin Diseases Stroke
Developmental/growth problems Depression
Infectious Disease (e.g., tuberculosis, hepatitis) Blood Disorders
Circulation/Vascular Problems Multiple Sclerosis
Diabetes/High Blood Sugar    
Hypoglycemia/Low Blood Sugar    
Other:
 
b.

Within the past year, have you had any of the following symptoms? Check all that apply:
   
Chest Pain Loss of Balance Bowel Problems
Heart Palpitations Difficulty Walking Weight Loss / Gain
Cough Joint Pain or Swelling Urinary Problems
Hoarseness Pain at night Fever/ Chills/Sweats
Shortness of Breath Difficulty Sleeping Headaches
Dizziness/Blackouts Loss of Appetite Hearing Problems
Nausea / Vomiting Vision Problems Coordination Problems
Weakness in Arms of Legs Difficulty Swallowing    
Other:
 
c.

Have you ever had surgery? 

    NO YES  
   

Please list them and include approximate dates.
                Month / Year
    Date /
    Date /
    Date /
6.

General Health Status
 
a.

Please rate your health:

  
   
Excellent Good Fair Poor
 
b.

Have you had any major life changes during the past year?
(e.g., new baby, job change, death of a loved one)
    NO YES  
7.

Social/Health Habits
 
a.
 Smoking:   Do you currently smoke tobacco?  NO YES
    Cigarettes, packs per day            Cigars / Pipes, per day.
    Have you smoked in the past?  NO YES     Year quit
 
b.
 Alcohol:  How many days a week do you drink beer, wine or spirits?
    How many drinks do you have on one average day?
 
c.
 Exercise:  Do you exercise beyond normal daily activities and chores?
    NO YES  
   

If  YES, how many days per week, on average, do you exercise?

   

How many minutes on an average day?

8.

Social History
 
a.

Cultural / Religious:   Are there any customs or religious beliefs that might affect care? 
Please explain
   
       

Signature of person completing this history form:
   
X _______________________________________________________
______________
Applicant's Signature
Date
       

This is the end of the survey.  Thank you! 
Your information will allow us to better meet your therapy needs.
   
X _______________________________________________________
______________
Reviewed By
Date